Hospitals and health care providers need financial support to respond to the pandemic and for future viability. In response, Congress allocated billions of dollars in relief funds through multiple existing and new programs. The disbursement of these funds is uncoordinated and so are public reports that track where the money is going, but states need to know how much these health care systems are getting.
Aided by an infusion of federal relief funds for housing and other support services, many states and cities are working to provide temporary housing to individuals experiencing or at risk of homelessness to keep them healthy and protected from COVID-19. But with difficult budget decisions ahead, it is important for states to consider the future implications of their short-term, emergency housing measures, and how to maximize government resources in the long-term.
Utilization of Rapid Re-Housing
Now more than ever, when homelessness is associated with high rates of coronavirus infection and renters are increasingly experiencing housing insecurity due to financial instability, housing assistance is critical in order to improve health outcomes and prevent individuals from living on the street or in crowded shelters. One way states are protecting individuals experiencing homelessness is through rapid re-housing, a program that provides individuals with tailored assistance packages and support, including short-term financial assistance, to help them move into housing quickly. Depending on the assistance and funding source, rapid re-housing can last up to two years.
Connecticut’s Department of Housing released guidance for housing providers to help expedite transitions into rapid re-housing. Ohio’s Franklin and Columbus counties also disseminated rapid re-housing guidance, including information on utilizing US Housing and Urban Development (HUD) waivers and providing case management services. Louisiana is using rapid re-housing to move individuals out of temporary hotel units and Rhode Island is prioritizing rapid re-housing for individuals who are currently homeless and awaiting placement in permanent supportive housing.
However, while studies indicate that only 10 percent of individuals in rapid re-housing programs return to homelessness, many do experience rental instability once their rapid re-housing assistance expires. In their guidance to homeless service providers during COVID-19, the Centers for Disease Control and Prevention encourages planning for ways to connect individuals experiencing homelessness with other housing opportunities after they leave temporary housing sites.
HUD’s Emergency Solutions Grant Program (ESG) is a common source of rapid re-housing funding. The Coronavirus Aid, Relief, and Economic Security Act (CARES) provided HUD with $4 billion in ESG funding, which the department began allocating to states in early April, and enables the expansion of rapid re-housing programs, among other housing initiatives.
In addition to ESG, state and local governments have access to a variety of other funding sources, including billions of dollars in allocations from the CARES act, which are designed to address housing needs during the pandemic. Both the ESG and Community Development Block Grant (CDBG) funding through CARES is being distributed in two waves, with the first wave released based on a FY 2020 allocation formula and the second wave, which has yet to be released, allocated to the highest-risk communities.
Encouraging an Equitable Approach to Resource Distribution
In order to guarantee that federal funding reaches the most at-risk individuals and is used in a cost-effective manner, ensuring the money is allocated equitably is critical. Communities of color and senior citizens are disproportionately affected by both COVID-19 and housing instability, and given the link between housing and health, supportive housing and rental assistance can improve health outcomes when used effectively. Because many housing assistance programs are locally run, rather than by the state, many cities are taking the lead and actively seeking ways to equitably allocate federal funding.
- The Chicago Continuum of Care (CoC) COVID-19 plan sets aside housing for individuals at high risk of serious illness due to COVID-19, as well as youth, those living on the street, and families. The Chicago CoC is also reviewing data to ensure that people of color are housed in rates proportional to their make-up of homeless individuals in Chicago, rather than by population numbers alone.
- In Seattle, the mayor promised to provide equitable access to rent assistance and noted that more than 70 percent of the rent support applications the city received came from people of color. The city is also working to help reduce barriers to housing assistance for seniors and non-English speaking residents.
In addition, HUD recently released a document detailing changes to coordinated entry prioritization for Continuums of Care as they respond to COVID-19. The guidance specifically notes the need to support individuals who are most vulnerable to COVID-19 and housing instability and calls on CoCs to consider the compounding effects of systemic inequities that contribute to high rates of homelessness among people of color when prioritizing housing assistance.
Increased Need for Supportive Services
In addition to using federal funds to support physical housing, states are also finding ways to ensure individuals experiencing homelessness receive other types of support services. Supportive housing combines housing assistance with wraparound services, such as behavioral and mental health services, substance use disorder treatment, and education and employment assistance. In addition to keeping individuals stably housed, supportive housing saves taxpayer money and reduces health care costs. The provision of wraparound services plays a critical role in helping individuals remain housed and healthy.
Given the extent of the public health emergency, there is an urgent need to help people access emergency housing and ensure they are simultaneously receiving critical health and support services. Coordinating case management and support services to ensure medication adherence and access to benefits, such as food stamps and health care coverage, can improve both health and housing outcomes. Some examples of support services that states can and are providing during the pandemic include:
- Connecting individuals living in temporary housing with federal nutrition services.
- Transitioning to telemedicine for substance use disorders treatment.
- Helping individuals released from institutional care, especially prisons, create a housing plan to avoid living on the street or in congregant areas, such as shelters.
- Utilizing HUD’s Continuum of Care Program to purchase cell phones and wireless plans in order to help individuals in shelters receive needed support services telephonically.
As states work to provide housing and supportive services to those in need, many questions and challenges arise:
- How can states optimally leverage and coordinate federal funds?
- How can states ensure that both newly homeless and chronically homeless individuals can access housing and supportive services in the future, after immediate funding and other resources expire?
With more people turning to rapid re-housing during COVID-19, state officials acknowledge that many individuals will require support not only during their transition into housing, but also after their short-term assistance expires, when they may need to transition to more permanent rental resources. Given the unprecedented loss in revenues to state coffers, most states anticipate deep budget cuts, which will make ensuring the sustainability of housing assistance even more difficult. As more individuals move into temporary housing, it will be critical for states to coordinate across health and housing agencies to maximize resources, housing stability, and positive health outcomes. Through its Health and Housing Institute, the National Academy for State Health Policy will continue to monitor and support states during this pandemic and beyond.
Below are examples of how states can address new needs, including housing, food, transportation, education, and employment, and how the CARES Act can support and amplify their work.
Housing: Homeless or housing-insecure individuals are at unique risk and more susceptible to the spread of COVID-19 because they have limited places to self-quarantine or isolate. These individuals may not have access to running water to practice safe hand-washing techniques. Title XII of the CARES Act includes funding to help sustain and expand states’ investments in homeless services and other emergency measures to ensure those individuals are able to stay healthy and to lessen the risk of community spread. These funds are intended to prevent, prepare for, and respond to COVID-19 and include appropriations of:
- $4 billion in Homeless Assistance Grants, available until Sept. 30, 2022;
- $1.25 billion to the Tenant Based Rental Assistance program, available until expended;
- $1 billion to the Project Based Rental Assistance program, available until expended;
- $6.85 million to the Public Housing Operating Fund, available until Sept. 30, 2021; and
- $5 million to the Office of Public and Indian Housing, available until Sept. 30, 2021.
The CARES act also appropriates funds for communities at higher risk of infection from COVID-19, including, under Title X, a $14.4 billion investment for veterans who are homeless or at risk of becoming homeless and under Title XII, $50 million directed to Housing for the Elderly, and $15 million to housing for people with disabilities, with funds available through Sept. 30, 2023.
- Examples of states’ current investments in shelter and emergency housing:
- California has authorized $150 million to protect homeless Californians from the spread of COVID-19. About $100 million is directed towards local government for shelter support and emergency housing to address COVID-19 in the homeless population and $50 million is directed to purchase trailers and lease rooms in hotels, motels, and other facilities in partnership with cities and counties throughout the state for immediate isolation placements for homeless individuals.
- Washington State’s Department of Commerce announced it is making $30 million available to use to expand shelters, buy more cleaning supplies, and other strategies, such as leasing motel rooms.
- State and federal initiatives to halt eviction processes:
- States, including New York, California, Maryland, and North Carolina, have implemented differing versions of a moratorium on evictions of residential and commercial tenants to ensure rent-insecure individuals do not lose their housing during this crisis and become more at risk. California’s order instructs its Public Utilities Commission to oversee customer service protections for services such as water, Internet, gas, and cell phone services.
- The US Department of Housing and Urban Development announced on March 18, 2020, an immediate foreclosure and eviction moratorium for single family homeowners with FHA-insured mortgages until the end of April.
- The CARES Act (Title IV Sec. 4024) also requires a temporary (120-day) pause on evictions proceedings, for any covered housing program as defined in section 41411(a) in the Violence Against Women’s Act, any rural housing voucher program, or has a federally backed mortgage loan.
Education: Most states (48 states and Washington, DC as of March 29, 2020) have closed schools and many are working to implement distance learning to comply with the CDC’s guidelines restricting social interactions. Distance learning is a strategy to keep not only children safe, but also their families, teachers, and administrators. However, it is important to consider that not all children and families have the appropriate technology or Internet capabilities at home to continue their education. School shutdowns illuminate the country’s “digital divide” – those who have access to the Internet and technology and those who do not – and demonstrates the inequities between wealthy and poor school districts, which can perpetuate and possibly worsen socio-economic and other disparities for individuals who have faced discrimination and are already underserved.
The CARES Act (Title VIII Sec. 18001) appropriates $30.75 billion in grants to school systems and higher education institutions to remain available through Sept. 30, 2021 through the Education Stabilization Fund, which provides emergency funds to aid in the continuation of educational services and supports both domestically and abroad. The act directs 1 percent of these funds for grants to states with the highest COVID-19 burden.
- Using state and federal funds allocated through public-private partnerships and local jurisdictions, many school districts, including in Connecticut, Florida, and Montgomery County, Maryland are distributing laptops and other technology as well as information about Wi-Fi hotspots to students, and encouraging parents of students with disabilities to reach out for extra support. New York City is prioritizing iPad distribution for students in temporary housing. Every district is trying to address the challenge of the digital divide in their community, including making hard-copy resources available for students who do not have immediate access to the Internet, and providing free Wi-Fi hotspot services from buses.
- The US Department of Education (DOE) announced it will approve waivers for any state that is unable to assess their students through standardized tests and report cards for the remainder of the school year due to the ongoing COVID-19 emergency. This change was implemented to protect student’s health and safety. DOE has approved these waivers in several states, including Arkansas, Colorado, Florida, Georgia, Indiana, Michigan, Oklahoma, Pennsylvania, Tennessee, and Washington State, and more states are considering this option.
- Virginia and Kansas have already announced their schools will be closed for the remainder of the school year, and other states may also close schools.
Food: Assuring access to healthy food, a critical determinant of health, is a challenge during a pandemic. States have determined that grocery stores are essential businesses, and food store workers are considered part of the critical infrastructure. To ensure underserved individuals maintain their ability to access healthy food in a safe way consistent with CDC guidelines, states are implementing various strategies. Additionally, the largest anti-hunger federal initiative is the Supplemental Nutrition Assistance Program (SNAP), and to ensure continuation of SNAP funding, the CARES Act (Title VI Division B) directs $15.8 billion to remain available until Sept. 30, 2021. Of this amount, $15.5 billion must remain in a contingency reserve until the secretary deems the funds necessary. The CARES Act (Title VI Division B also appropriates $8.8 billion to Child Nutrition Programs, also available until Sept. 30, 2021. Several state and strategies to ensure at-risk populations have access to nutrition are listed.
- Providing meal delivery services:
- The school lunch program is the second-biggest anti-hunger initiative after SNAP. To ensure students who receive free or reduced-price lunches at schools do not go hungry while state-mandated school shutdowns are in place, at least 25 states were approved for US Department of Agriculture (USDA) waivers that authorize school meal distribution. Maryland and Florida have developed websites with interactive maps of the states’ locations for grab-and-go meals. Cities and counties are working in collaboration with states to ensure all students are able to get their meals, even if they are living with at-risk relatives. Loudoun County in Virginia, Wayne Township in Indiana, and Cambridge, Massachusetts are all using school buses to deliver meals to those students.
- Arizona, California, Ohio, and Texas governors all directed their National Guard units to be on alert to aid in food delivery for vulnerable populations, including elderly individuals.
- The CARES Act (Title VI Division B) appropriates $100 million for the USDA Food Distribution Program directly to Native American reservations.
- Arizona and Iowa’s approved 1135 waivers for Medicaid Emergency Authority both expand eligibility for home-delivered meals. Arizona’s waiver expands access to all eligible populations, and Iowa’s waiver expands eligibility to non-waiver members who are home-bound and waiver members even if the waiver does not have meals as an allowable service.
- Modifying restaurant services:
- Most states (42 states and Washington, DC as of March 25) have halted “dine-in” options for restaurants and bars to slow and limit the spread of the coronavirus. For example, the Colorado Department of Public Health, like many other states, issued a public health order to close bars, restaurants, and other establishments though they are still permitted to provide delivery service, window service, and drive-through services with precautions.
Transportation: Access to transportation services is an important determinant of health, but to aid in social distancing and limit spread, states are recommending people limit their use of public transportation by working remotely and using telemedicine services to reduce unnecessary travel so that public transportation can be safer for those who depend on it, such as transit operators, essential health care workers, and grocery store employees. The CARES act (Title XII) also appropriates $25 billion in funding, available until expended, to support this the infrastructure of operating expenses for transit agencies related to the response of to the coronavirus public health emergency.
- Modifying public transportation services:
- Relaxing telehealth requirements
- States are rapidly relaxing telehealth requirements to address coronavirus symptoms. For example, the Massachusetts Department of Public Health issued guidance that all insurers are required to cover medically necessary telehealth services in the same manner they cover in-person services. Texas and Michigan have issued guidance that allows providers to establish patient-physician relationships via telemedicine, including phone calls. Other states, including Louisiana and West Virginia, are relaxing Medicaid requirements to allow emergency and non-emergency evaluation visits to be conducted via telemedicine. These changes are vital to ensure that everyone in the state can still access health services while taking precautions against unnecessary potential viral spread.
- The CARES Act (Part II Sec. 4213) reauthorizes Health Resources and Services Administration’s (HRSA) grant programs that promote telehealth services, which offers flexibility for Medicare patients at risk of contracting COVID-19, and aids in screening patients avoiding their exposure to others.
- The CARES Act (Part II Sec. 4214) also reauthorizes HRSA grant programs that strengthen rural community health through quality improvement, increased access to care, and improvement in coordination to care. This is especially important because rural residents are disproportionately older and more likely to have a chronic disease, which increases their risk for coronavirus.
Employment benefits: Many states, including Maryland, New Jersey, and North Carolina, have implemented telework policies and are encouraging all employers to allow telework opportunities to aid in social distancing. However, many state employees, including sanitation workers, health workers, and retail workers do not have the ability to work remotely, and require protection and benefits to ensure they stay healthy and able to do their jobs. Many retail workers are part-time hourly employees and do not have access to sick leave so states are taking initiatives to create equitable policies for their more vulnerable residents who are providing critical services during this pandemic. The federal government is following states’ lead in developing policies to support individuals with benefits and supports that are essential to respond to the pandemic.
- Classifying emergency workers:
- Minnesota and Vermont have classified grocery store workers and food distribution workers as essential personnel. This change classifies grocery and food distribution workers as first responders, critical to their states’ response to coronavirus. This classification qualifies them for special child care provisions. This is especially important because these workers tend to be paid hourly, and often do not have access to comprehensive benefits.
- The CARES Act (Title VIII) proposes an additional $3.5 billion in funding to states and territories, available through Sept. 31, 2021, through the Child Care and Development Block Grant to provide childcare assistance to low-income families. The funds may also be used for continued payment and assistance to child care providers to health care employees, emergency responders, sanitation workers, and other employees deemed essential to the response to coronavirus.
- Paid sick leave:
- Several states have paid sick leave policies in place. When Colorado declared a state of emergency on March 10, 2020, the declaration allowed workers in certain covered industries, including hospitality, food services, child care, education, transportation, and home health, up to four days of sick leave when experiencing flu-like symptoms and awaiting test results for COVID-19.
- The CARES Act (Subtitle C Sec. 3602) authorizes paid sick leave benefits for employers with employees who are sick or seeking care for coronavirus or need to take leave to care for quarantined individuals, including their children. The payments are capped at $511 per day per employee who is sick or seeking care, and $200 a day for employees who are caring for a sick family member.
- Unemployment benefits:
- States are creating unemployment compensation benefit plans. For example, Alabama and Pennsylvania have implemented a policy to allow individuals who are employed but unable to work because of COVID-19 to file for unemployment benefits.
- The CARES ACT (Title II Sec. 2102) creates a temporary Pandemic Unemployment Assistance program to provide payment to individuals who are not eligible for traditional unemployment benefits (e.g., self-employed, independent contractors, those with limited work history, and others) and are unable to work as a direct result of the coronavirus public health emergency for reasons including:
- They are seeking a COVID-19 diagnosis;
- Are providing care for someone sick with COVID-19;
- Are providing care to a child or someone in their household who is unable to attend school or another facility that has been closed because of c COVID-19;
- Are unable to get to work because of a COVID-19-related quarantine. Individuals who have the ability to telework with pay or are receiving paid sick leave or other paid leave benefits do not qualify for these funds.
- These funds are available to those who experienced unemployment, partial unemployment, or inability to work from Jan. 27 through Dec. 31, 2020.
State policymakers have led the way in taking aggressive steps to address the impact and stop the spread of COVID-19. They have recognized that vulnerable populations need special attention and protections and have launched efforts to address a myriad of health-related social needs. The federal government is adding needed support through the CARES Act, which will allow states to invest in their residents’ social and medical needs. Many of these efforts are stop-gap measures in a time of crises and raise questions about how policies will continue to address the health and social disparities that the crisis exacerbates after the immediate emergency period is over.
In a Washington Post op-ed, Richard Besser, president of the Robert Wood Johnson Foundation, notes, “Every long-term solution must be viewed through the health equity lens, for if they are not, we’ll be setting the stage for our next public health failure.” States are working hard to address both health and health-related social needs emerging from COVID-19, and the National Academy for State Health Policy will continue to track implementation of state’s critical policies to assist states with replication.
Support for this work was provided by the Robert Wood Johnson Foundation. The views expressed here do not necessarily reflect the views of the foundation.